Child Welfare Licensed Facility Forms and Publications

Group Home, Residential Care Center, Shelter Care, Child Placing Agency

The Department of Children and Families (DCF) has created a number of forms and publications for group homes, residential care centers, shelter care, and child placing agencies. Some, but not all, of these forms are mandatory. These forms and publications can be found below and are searchable by facility type. To view forms and publications for a facility type, chose the facility from the drop-down menu below. F/P?   F=Forms and P=Publications. Publications do not have a status. Click on the sort arrows next to the columns to help find the documents you need.

Use the selection list below to find all the forms for a specific facility type.

Form/Publication Name Number Status File Format F/P? Key
Caregiver Background Checks Substantially Related Investigation Report for Child Welfare Agencies DCF-F-5160-E Voluntary Word F GH, RCC, SC, CPA
Fire Safety Inspection - Shelter Cares DCF-F-4147-E Mandatory Word F SC
Reasonable Prudent Parenting Decision Record DCF-F-5124-E Mandatory Word F GH, RCC, SC, CPA
Child Welfare Vehicle Safety Inspection DCF-F-4148-E Mandatory Word F GH, RCC, SC, CPA
Reasonable and Prudent Parenting Standard Review DCF-F-5123-E Voluntary Word F GH, RCC, SC, CPA
Adoption Assistance Agreement DCF-F-CFS0074-E Mandatory Word F CPA
Adoptive Family Placement Agreement  DCF-F-CFS00140 Mandatory PDF F CPA
Adoptive Placement Checklist - Child Placing Agency - Domestic DCF-F-CFS2259 Voluntary Word F CPA
Adoptive Placement Checklist - Child Placing Agency International DCF-F-CFS2155 Voluntary Word F CPA
Affidavit - A birth parent's consent to allow contact information to be given to their adult adopted child. DCF-F-CFS0142-E Voluntary Word F CPA
Affidavit - A birth parent's consent to allow contact information to be given to their adult adopted child. DCF-F-CFS0142-E-H (Hmong) Voluntary PDF F CPA
Affidavit - A birth parent's consent to allow contact information to be given to their adult adopted child. DCF-F-CFS0142-E-S (Spanish) Voluntary PDF F CPA
Amendment Request to Extend Care to Residents 18 Years of Age and over, but under 21 DCF-F-5081 Mandatory PDF F GH, RCC, SC, CPA
Application to DCF Exceptions Panel for Exception to Ch. DCF 56 DCF-F-CFS0847-E  Mandatory PDF F GH, RCC, SC, CPA
Assessment and Discharge Summary - Respite Group Homes DCF-F-2831 Voluntary Word F GH
Assessment and Treatment Plan - Residential Care Centers for Children and Youth DCF-F-2440 Voluntary Word F RCC
Assessment, Treatment Plan and Discharge Plan - Group Homes for Children DCF-F-CFS2430 Voluntary Word F GH
Background Check Information Schedule – Child Placing Agencies DCF-P-PFS4075D   PDF P CPA
Background Check Information Schedule Group Home, Shelter Care, and Residential Care Centers for Children and Youth DCF-P-PFS4075C   PDF P GH, RCC, SC
Background Information Disclosure (BID)  DCF-F-2978-E Mandatory Word F GH, RCC, SC, CPA
Background Information Disclosure (BID) DCF-F-2978-E-S (Spanish) Mandatory Word F GH, RCC, SC, CPA
Background Information Disclosure (BID) DCF-F-2978-E-H (Hmong) Mandatory Word F GH, RCC, SC, CPA
Child Foster Care Licensing Checklist DCF-F-CFS0787 Mandatory PDF F CPA
Child Placing Agency Foster Child Record Checklist DCF-F-CFS0380 Voluntary PDF F CPA
Child Record - Shelter Care Facilities DCF-F-CFS2389-E Voluntary Word F SC
Child Record Checklist - Group Homes DCF-F-CFS0379 Voluntary Word F GH
Child Record Checklist - Shelter Care Facilities DCF-F-CFS2414 Voluntary Word F SC
Child Welfare Applicant/Licensee Rights and Responsibilities DCF-P-2498   PDF P GH, RCC, SC, CPA
Child Welfare Request for Exception DCF-F-5023-E Mandatory Word F GH, RCC, SC, CPA
Child Welfare Request for Exception - Age DCF-F-5085 Mandatory Word F GH, RCC, SC
Child Welfare Request for Exception - Age DCF-F-5085 Mandatory Word F GH, RCC, SC
Child's Personal Record DCF-F-CFS0103 Voluntary PDF F GH, RCC, SC, CPA
Community Advisory Committee Documentation DCF-F-CFS0367-E Mandatory PDF F GH, RCC
Community Living Arrangements DCF-P-5106-H (Hmong)   PDF P GH, RCC
Community Living Arrangements  DCF-P-5106-S (Spanish)   PDF P GH, RCC
Community Living Arrangements   DCF-P-5106   PDF P GH, RCC
Continuing Education Record - Independent Reading / Video Viewing DCF-F-CFS2114 Voluntary PDF F GH, RCC, SC, CPA
DCF 12 Negative Action Notice DCF-F-CFS2191 Voluntary PDF F CPA
Email Subscription Service DCF-P-5107-H (Hmong)   PDF P GH, RCC, SC, CPA
Email Subscription Service DCF-P-5107-S (Spanish)   PDF P GH, RCC, SC, CPA
Email Subscription Service  DCF-P-5107   PDF P GH, RCC, SC, CPA
Fire Safety and Emergency Response Documentation - Group Homes DCF-F-CFS2384 Voluntary PDF F GH
Fire Safety and Emergency Response Documentation - Residential Care Centers for Children and Youth DCF-F-CFS2383 Voluntary PDF F RCC
Fire Safety and Emergency Response Documentation - Shelter Care Facility DCF-F-CFS2385 Voluntary PDF F SC
Fire Safety Inspection - Group Homes DCF-F-CFS0909 Voluntary PDF F GH
Fire Safety Inspection - Residential Care Centers DCF-F-CFS0357 Voluntary PDF F RCC
Foster Home Agreement Child Placed In Out-of-Home Care by Agency DCF-F-CFS0107-E Mandatory Word F CPA
Foster Home Information for WiSACWIS DCF-F-CFS2386 Mandatory Word F CPA, Foster
Foster Home Licensure Notification DCF-F-CFS2187-E Voluntary PDF F CPA
Foster Home Record Checklist - Child Placing Agencies DCF-F-CFS0381 Voluntary Word F CPA
Foster Parent Insurance Program Claim of Loss or Damage DCF-F-CFS0116 Mandatory PDF F CPA
Foster Parent Insurance Program Damage Claim Checklist DCF-F-CFS2198-E Voluntary Word F CPA, FC
Foster Parent Insurance Program Verification of Claims DCF-F-CFS0117-E Mandatory PDF F CPA
How to Access Forms for Child Welfare Facilities DCF-P-PFS4098   PDF P GH, RCC, SC, CPA
ICPC Placement Request DCF-F-CFS0100A Mandatory Word F GH, RCC, SC, CPA
ICPC Report on Child's Placement Date or Change of Placement DCF-F-CFS0100B Mandatory Word F GH, RCC, SC,, CPA
Out-of-Home Care Providers - Part A CFS0872A Mandatory Word F GH, RCC, SC, CPA
Out-of-Home Care Providers - Part B CFS0872B Mandatory Word F GH, RCC, SC, CPA
Intake Information - Group Home Resident DCF-F-CFS2382A-E Voluntary Word F GH
Intake Information - Group Home Resident Under 6 Years of Age DCF-F-CFS2382B-E Voluntary Word F GH
It Shouldn't Hurt to be a Child DCF-P-PFS0101   PDF P GH, RCC, SC, CPA
It Shouldn't Hurt to be a Child: Ser niño no debería doler DCF-P-PFS0101S (Spanish)   PDF P GH, RCC, SC, CPA
It Shouldn't Hurt to be a Child: Ua ib tug me nyuam yuav tsum tsis txhob raug mob DCF-P-PFS0101H (Hmong)   PDF P GH, RCC, SC, CPA
Licensing Checklist - Child Placing Agencies DCF-F-CFS0362 Mandatory Word F CPA
Licensing Checklist - Group Homes  DCF-F-CFS0358 Mandatory Word F GH
Licensing Checklist - Residential Care Centers DCF-F-CFS0354 Mandatory Word F RCC
Licensing Checklist - Shelter Care Facilities DCF-F-CFS0361 Mandatory Word F SC
Medical Services Consent DCF-F-CFS0997 Voluntary PDF F GH, RCC, SC, CPA
Medical Services Consent DCF-F-CFS0997-H (Hmong) Voluntary PDF F GH, RCC, SC, CPA
Medical Services Consent DCF-F-CFS0997-S (Spanish) Voluntary PDF F GH, RCC, SC, CPA
Medical Services Consent - Child Welfare Facilities DCF-F-CFS2379-E Voluntary PDF F GH, RCC, SC, CPA
Medication Administration Record - Group Homes for Children DCF-F-CFS2338 Voluntary PDF F GH
Notice to Foster Parents Regarding Confidentiality of Records DCF-F-CFS2186 Voluntary PDF F CPA
Notice to Foster Parents Regarding Confidentiality of Records: Aviso Para Padres de Crianza en Referencia a la Confidencialidad de los Registros  DCF-F-CFS2186S (Spanish) Voluntary PDF F CPA
Ordering Information - Child Welfare Licensing Inquiry Packets DCF-F-2491 Mandatory PDF F  CPA, SC
Out-of-Home Placement Notification or Recommended Placement Notification DCF-F-CFS2189 Voluntary PDF F GH, RCC, SC, CPA
Personnel Record Checklist - Child Placing Agencies DCF-F-CFS0369 Voluntary PDF F CPA
Personnel Record Checklist - Group Homes DCF-F-CFS0383 Voluntary Word F GH
Personnel Record Checklist - Shelter Care Facilities DCF-F-CFS2399 Voluntary Word F SC
Personnel Requirements - Child Placing Agency DCF-P-2913   PDF P CPA
Personnel Requirements - Group Homes for Children DCF-P-PFS4100   PDF P GH
Policy/Procedure Checklist - Child Placing Agency DCF-F-2850-E Voluntary Word F CPA
Policy/Procedure Checklist - Group Homes for Children DCF-F-CFS2378 Voluntary Word F GH
Rate Regulation DCF-P-5108-S (Spanish)   PDF P GH, RCC, CPA
Rate Regulation DCF-P-5108   PDF P GH, RCC, CPA
Rate Regulation DCF-P-5108-H (Hmong)   PDF P GH, RCC, CPA
Rehabilitation Review Application and Instructions DCF-F-419-E Mandatory Word F GH, RCC, SC, CPA
Request by Shelter Care Facility to Accept Voluntary Placements and/or to Provide Respite Care Services DCF-F-5041-E Mandatory Word F SC
Resident Orientation Documentation - Group Homes DCF-F-CFS2381-E Voluntary PDF F GH
Resident Record Checklist - Residential Care Centers for Children and Youth DCF-F-CFS2139-E Voluntary Word F RCC
Residential Care Center Child Abuse and Neglect Reporting and Confidentiality Responsibilities DCF-F-CFS2172 Mandatory PDF F RCC
Residential Care Center General Personnel Record Checklist DCF-F-CFS2140 Voluntary Word F RCC
Residential Care Center Policy/Procedure Checklist DCF-F-CFS2168 Voluntary Word F RCC
Residential Care Center Statutorily Reportable Death DCF-F-CFS2183 Mandatory Word F RCC
Rights of Minors in Inpatient Community Mental Health Facilities P-20470A   PDF P GH, RCC, SC, CPA
Sanitation Checklist - Residential Care Centers DCF-F-CFS0353 Voluntary PDF F RCC
Serious Incident Report DCF-F-CFS2146-E Mandatory PDF F GH, RCC, SC, CPA
Staff / Volunteer Orientation Documentation - Group Homes DCF-F-CFS2380-E Voluntary PDF F GH
Staff Continuing Education and Training Record Child Welfare Programs DCF-F-CFS2142 Voluntary PDF F GH, RCC, SC, CPA
Staff Health Report - Child Welfare Facilities DCF-F-CFS0384 Voluntary PDF F GH, RCC, SC
Use of 10+ Passenger Vans To Transport Children To and From Schools DCF-P-PFS4088   PDF P GH, RCC, SC, CPA
Voluntary Placement Agreement DCF-F-CFS1590 Mandatory Word F GH, RCC, SC, CPA
Voluntary Placement Agreement DCF-F-CFS1590-H (Hmong) Mandatory Word F GH, RCC, SC, CPA
Voluntary Placement Agreement DCF-F-CFS1590-S (Spanish) Mandatory Word F GH, RCC, SC, CPA
Voluntary Placement Agreement for Shelter Car DCF-F-5040-E-S (Spanish) Mandatory PDF F SC
Voluntary Placement Agreement for Shelter Care DCF-F-5040-E-H (Hmong) Mandatory PDF F SC
Voluntary Placement Agreement for Shelter Care  DCF-F-5040-E Mandatory Word F SC
Adoption Assistance Agreement DCF-F-CFS0074-E-H (Hmong) Mandatory PDF F CPA
Adoption Assistance Agreement DCF-F-CFS0074-E-S (Spanish) Mandatory PDF F CPA
Rehabilitation Review Application Instructions DCF-F-419-H (Hmong) Mandatory PDF F GH, RCC, SC, CPA
Rehabilitation Review Application Instructions DCF-F-419-S (Spanish) Mandatory PDF F GH, RCC, SC, CPA
Disaster Plan DCF-F-5129-E Mandatory Word F GH, RCC, SC